GPs resist CVD assessment

AUSTRALIA must follow New Zealand’s lead and improve the uptake of absolute risk assessment of cardiovascular disease by GPs, says the man who helped write the guidelines for the assessment of absolute cardiovascular disease risk.

Dr Robert Grenfell, chair of the National Vascular Disease Prevention Alliance (NVDPA), was responding to a qualitative study published online by the MJA today identifying five strategies GPs use to assess cardiovascular disease (CVD) risk in their patients. (1)

The researchers interviewed 25 NSW GPs in 2011–2012 and found the use of absolute risk (AR) assessment varied widely, from closely following the guidelines to rejecting these in favour of other priorities for patient care. Patient factors also influenced the use of AR.

They identified five strategies used by GPs to assess risk: AR-focused, used when AR assessment was considered useful for the patient; AR-adjusted, used to account for additional risk factors such as family history; clinical judgement strategy, used when GPs considered their judgement took multiple risk factors into account as effectively as AR; passive disregard strategy, used when GPs did not have time or access to an AR calculator; and active disregard strategy, used when AR was considered inappropriate for the patient.

“The main facilitators for using AR assessment were trusting AR tools over clinical judgement, uncertainty about treating patients who were borderline high risk, and opportunities to motivate patients at high risk or reassure patients at low risk”, the researchers wrote. They said GPs’ descriptions of alternative strategies demonstrated a range of barriers to the use of AR assessment.

The NVDPA guidelines recommend that AR assessment, to predict the risk of a cardiovascular event over the next 5 years, be performed for all adults aged 45–74 years (or over 35 years if the patient is Aboriginal or Torres Strait Islander) who are not known to have CVD or to be at increased risk of CVD. (2)

Dr Grenfell told MJA InSight he believed uptake of AR was much lower than the MJA study suggested.

“The Heart Foundation has been doing annual surveys of GPs, practice nurses, cardiologists and heart attack survivors for more than a decade”, he said. “Most GPs say they know about AR and say they’re doing it, but when you drill down a little further you find that only about 5% to 10% are using an AR calculator.

“There is considerable resistance from the GP workforce about using combined risk factors in CVD assessment.”

Dr Grenfell said New Zealand was leading the way in terms of successful uptake of AR assessment and a subsequent slowing in the progress of the disease.

“In 2002 they were in the same position we are in now, but by April of 2014, 90% of the [targeted demographic] will have had a combined health risk assessment done”, he said.

“That’s 300 000 Kiwis assessed with a 2.5-year follow-up. They’ve achieved that through 10 years’ hard work as well as very solid political ownership, good leadership from cardiologists and GPs, direct funding, incentives for GPs, and education for practitioners and consumers.”

Another factor was a competitive price for statins, he said.

“They have the right people taking the right drugs and because they have an attractive statin price, the government doesn’t have to take a great risk in supporting that.”

In Australia, the aim was to have every Australian over age 45 years aware of their cardiovascular risk by 2023.

Dr Grenfell said if the new federal government was serious about reducing big-ticket items like hospital admissions, “then this is the space they should be working in”.

Professor Mark Nelson, chair of the discipline of general practice at the University of Tasmania, said resistance from GPs about AR assessment was based on moving away from the established practice of treating an isolated risk factor, like high blood pressure, universally above a designated cut-point.

“The problem is that we are giving medication to people who are very unlikely to benefit from it”, Professor Nelson told MJA InSight. “But more importantly we are failing to identify the high-risk patients who are most likely to benefit.

“An example of someone likely to benefit from AR assessment would be a late middle-aged male who smokes and has mildly elevated other risk factors”, he said.

“Whenever I talk to fellow GPs we complain about the difficulty in changing our patients’ behaviours, but often fail to change our own.”

3 thoughts on “GPs resist CVD assessment”

Interesting comments from Dr Grenfell. I am not sure if the fall in the NZ figures in cardiovascular mortality however are arising from the use of the Absolute Risk Calculators or by policy adjustments in the availability and cost of statins. I resist somewhat the global implication that GP’s need to be doing more, in an age where over screening and overdiagnosis are also in common parlance.

I find the rather narrow view of treating to a number a contextural difficulty at times in General Practice. I know Dr Grenfell used to practice as a rural GP in a large farming community and I am certain he experienced similar difficulties.

Please pause on You tube link below and read the quote provided by Professor Iona Heath at a Plenary Speech at a medical conference in the UK ( Obtained via Prof Paul Glasziou on the oft maligned Social media Platform Twitter)

This MJA article is a worthy reminder on the necessity for comprehesive CVD risk factor assessment however let’s not malign General practice any further as the patient may well have come in for a skin check, a pap smear, and a mental health plan in a 15 minute consultation. Asking them to return for follow up when as for example you are a Rural GP and you are booked out a month or so in advance may be a problem. Let’s not malign general practice at all but understand why evaluating a full CVD risk assessment in Australian General Practice is problematic, and whether it is this issue of failing to use AR, or the price of statins that have changed the game in the NZ outcome figures. A headline that Australian GP’s are 10 years behind their NZ colleagues does nothing to attract new blood into the profession, nor boost the morale of those of us remaining at the coal face. It is perhaps not as simple as the article or the headline implies.

By the way Professor Heath’s plenary is 15 minutes long and well worth a full viewing.

We treat patients not numbers and hopefully in that order.

The other neglected issue here is the time available for GP’s to run full assessments and the rather absurd incentive that the Medicare Benefits Schedule formulates in that the quicker you see your patient, the more you earn. Another elephant in the room.

I think one of the reasons for the poor uptake is that the calculators are

1.somewhat clumsy to use. for that reason I’ve been an ardent user of the NZ web based “know your numbers” which presents the matter to patients in a clear way, and also has the ability to use slides to vary the parameters visually. Can be done in as part of the consult easily.

2. that the prediction is for a 5 or 10 year period- which is too short a time frame for some of these preventative activities. Eg borderline elevation of bp and or lipids in a say 50 yr old male may calculate out at low risk at 5 years. But as the development of atherosclerotic disease is a long process surely we should be assessing risk at 10, 15, 20 years ahead. Do we have those numbers? Why not make the calculators reach out that far.

3. That there is significant variability and apparent inconsistency between various calculators – which creates doubts in the minds of many.